On Jan. 31, the International Journal of Eating Disorders published the largest study to date on eating disorders among professional models, which confirmed that models are often pressured to lose weight and jeopardize their health in order to book jobs.

The study was a joint effort between researchers at Northeastern University, Harvard T.H. Chan School of Public Health, and The Model Alliance, a labor advocacy group for models in the American fashion industry. The landmark study aimed to "bridge a gap in data" on the pressure to lose weight and the rates of unhealthy weight control behaviors among models — and to use this evidence to suggest policy changes in the industry.

"It's also the first study to link disordered eating among models with perceived pressure from agencies," Rachel Rodgers, PhD, principle investigator and professor of applied psychology at Northeastern University, told BuzzFeed Health.

Researchers sent out an anonymous survey to female models over the age of 18 who participated in New York Fashion Week (NYFW) in February 2016; 85 models completed the survey. IMG, which produces New York Fashion Week, did not immediately answer our request for the total number of women who participated in NYFW last year. However, the study co-author estimates that about 450 female over-18 models will participate at NYFW castings and runway shows. It's also noted in the study that the recruitment methods might have led to a sample that was not representative of all professional female models.

Among the sample of models, 81% had BMIs that were classified as underweight.

BMI, or body mass index, is a number used to determine your body mass based on your height and weight. It's calculated by taking a person's weight in kilograms divided by the square of their height in meters. It's often used as a screening tool — mostly at the population level — for obesity or metabolic disease, but it doesn't directly measure body fat or overall health in individuals. It also doesn't take into consideration things like nutrition, activity level, muscle mass, or bone density.

A BMI under 18.5 is classified by the World Health Organization as underweight. In this study, the mean BMI of participants was 17.5, with the lowest being 14.5. The majority of models surveyed (81%) had a BMI under 18.5. As noted above, BMI is not a perfect measure of health or body fatness, and some models did claim they were healthy and naturally thin.

The study found a high prevalence of unhealthy weight-control behaviors such as skipping meals, fasts, detoxes, using diet pills, vomiting, and abusing stimulants or cocaine.

They also found that 62% of models were asked to lose weight or change their shape, 54% were told they wouldn't book jobs unless they lost weight, and 21% were told their agency would stop representing them unless they lost weight.

Models reported a high prevalence of pressure from their agencies to lose weight or change their appearances, reporting that they "sometimes, often, or always" experienced the following: were told they would be more successful if they lost weight (63%), were given diet or exercise regimens to lose weight (57%), were told they should get cosmetic surgery (9.3%), and were given diet pills, weight-loss supplements, or other "substances" to lose weight (7.2%).

"Most of these models are teens or young adults, so being dangerously underweight and having an eating disorder can have serious consequences on growth and development that affect them for life," Rodgers says.

The more dangerous weight-loss practices, such as drug abuse and vomiting, can result in more immediate health problems. "Self-induced vomiting can cause severe bodily dysfunctions, heart strain, electrolyte imbalances, drops in blood pressure, and fainting," Rodgers says. According to the NIH, anorexia nervosa is the most fatal mental disorder, with a mortality rate of about 10%.

The study was published just as the modeling and fashion industries gear up for their biggest event of the year: New York Fashion Week, which takes place February 9–17.

The purpose of publishing this study before one of the biggest fashion industry events in the world was to call attention to the models under the clothes and recognize them as laborers, Sara Ziff, study co-author and founder of The Model Alliance, says, who deserve health and safety protections just like any other laborer.

In an open letter to New York Fashion Week, current models and the National Eating Disorders Association (NEDA) cited the study as proof that the industry needs to change to promote health and diversity.

Members of the modeling community, The Model Alliance, and NEDA challenged designers, agents, and everyone involved in NYFW to the following:

* Make a serious commitment to promote health and diversity in terms of race, size, and gender.

* Uphold the idea that models under 16 do not belong on the runway, as their prepubescent bodies make them unsuitable to market clothing to adults.

* Observe child labor laws in New York State, which require that models under 18 have proper documents and schedules.

* Review the latest research on eating disorders and unhealthy weight control practices in the fashion industry and commit to working collaboratively with medical experts and industry stakeholders.

"We now have a study which provided solid scientific proof that eating disorders are a serious health problem in the modeling industry, and that makes it more difficult for designers to ignore," Ziff said.

"I was booked the most when I was at the height of my eating disorder, a size 0 at 5'9". Now I'm still very thin but a size 4 and I don't get hired for any of the same jobs," model Renee Peters told BuzzFeed Health.

Peters, a 28-year-old model and blogger living in New York City, is one of the models in support of the open letter. She's pictured above in an Instagram with the caption: "Embracing my body as a size 4 after years of under eating. Self love is worth more than any client or casting directors' opinion could ever be..."

She said that the pressure to be thin from agencies and designers led her to develop an eating disorder for several years. Peters is now recovered and said her current agency doesn't pressure her to lose weight, but she said the industry still gives the most jobs to models who are severely underweight.

"The agencies know how to get away with it — they'll ask you to lose inches instead of pounds and say it's possible with exercise and green tea, but that's not how you drop 20 pounds when you're already too thin," model Miranda Frum told BuzzFeed Health.

Frum, a 25-year-old model living in Los Angeles who also supports the letter, said she was set to walk in a show at NYFW a few years ago but was cut because she couldn't fit in the runway size. That year, she said "it was normal to see models with shoulder blades and knees popping out."

The disordered eating practices also took a toll on her immune system. "When I was 22 and modeling in Paris, I got really sick from having no nutrition and the night before a big shoot I had acute bronchitis and a fever but I couldn't cancel. When I got there, they told me I looked old and haggard and I was cut from my agency," Frum said.

Frum said she believes the industry has normalized the pressure to lose weight through unhealthy or obsessive practices. “The demented part is you don't even see your body as other people see it, as extremely thin, after so many years of bad and unhealthy advice from agents about how you're supposed to look compared to other models,” said Frum.

Even when models recognize unhealthy and unsafe practices in the industry, Frum said many fail to speak up, fearing that it will hurt or end their career.

"There’s a stigma in the industry that if you’re a model who speaks out, it means you just weren’t that good or you’re bitter," Frum said. Even though many models want to speak up, they often fear that they will get dropped from their agency or become an outcast and never find modeling work again.

It's also worrying, said Frum, that some young women begin modeling in the US as a lucrative way to support themselves or their families, and may feel "stuck" doing whatever is necessary to keep their job. (Among the models in the study, 59% were US citizens, 7% were legal residents, and 34% were visitors or other nonresidents.)

Ziff told BuzzFeed Health she blames "exclusive contracts," which prohibit models from finding jobs without their agents, as a major reason agencies can have so much control over models' weights.

"The way the industry is structured, a model can’t book jobs independent of her agent so they are her only access to employment — if the agent refuses to book her unless she loses weight, this creates an extremely coercive and dangerous work environment," Ziff, an agency-represented model herself, said.

Because there are no policies that protect the health and safety of models as laborers, agencies who ask models to lose weight are technically not breaking any laws.

Eating disorders are an occupational hazard in the modeling industry, Ziff said, and the study shows that there's an urgent need for interventions to combat the control agencies exert over models' lives.

Another issue? The sample size for women's clothing is a 0–2, a size that's often difficult for adult models to fit into, which can lead agencies to book young girls instead.

"Designers end up hiring girls who are only 14, 15, 16 because they're the only models agencies send who can fit in these small sizes, and it puts immense pressure on models as they get older and fill out, as all women do," Ziff said. And now, there's data to back up this claim: Among this sample, the mean age participants began modeling was 16.8 years old.

The industry either needs to make the sample size larger so it's appropriate for adult women, Ziff said, or to introduce several sample sizes to fit a larger range of bodies. Essentially, it should be more difficult for pubescent girls to model women's clothing, Ziff said, because it sets a very unhealthy body image standard for both models and consumers.

And it's not just a problem for models — researchers say an unhealthily thin "ideal body" in the media can in turn increase eating disorder risk at the population level, creating a public health issue.

The purpose of the study was also to create policies to combat this issue, as there are currently no policies or laws in the US to protect models other than voluntary efforts among designers.

One proposed solution was imposing a minimum BMI threshold, which would require agencies to represent only models with a BMI of 17 or above. According to the study, models believed that this would limit models who are naturally thin, and they argued that BMI isn't a complete indicator of health. Another major loophole was that models can attempt drastic, rapid weight loss in the time between their BMI check-in and a fashion show.

According to the models surveyed, the most feasible and impactful policy would be one that requires employers to provide food and a 30-minute break for jobs longer than six hours, a seemingly reasonable request.

According to the study, models are considered independent contractors rather than full-time employees, which allows for poor health and safety measures.

For that reason, models showed the most support for policies which provided specific measures for healthier working conditions and employer protections, like breaks and meals which actors or musicians normally enjoy on set.

"No matter what the industry says, the body type on the runway isn't changing — and we have scientific proof now that it's a public health and labor protection problem, which requires urgent policy," said Ziff.

“The study makes clear that while some models are naturally very thin, a lot of models are willing to go to extremes and compromise their health to achieve the ‘ideal body’ according to the industry’s standards,” Ziff said.

The study researchers hope these findings will help promote a healthy and safe working environment for models, decrease the "glorification of extreme thinness in the media," and engage models and other fashion industry professionals as key stakeholders to continue research and develop policies that help prevent the risk of eating disorders.

If you or someone you know is suffering from an eating disorder or engaging in unhealthy weight control practices, visit the NEDA website for support or call their confidential, toll-free hotline at 1-800-931-2237.